The ongoing impact of the Affordable Care Act

Analysis shows that administrative changes to the ACA and public debate appear to have no effect on gains in coverage or health outcomes
September 30, 2020

Although it has been a source of political strife since it was signed into law a decade ago, the Affordable Care Act (ACA) has had notable positive effects on American health care access and health. Previous research has found that subsidized health insurance coverage through the ACA individual Marketplace and expansions of various state Medicaid programs led to improved access to health care and better self-reported health (Courtemanche et al. 2018). However, not as much is known about how subsequent changes in the individual Marketplace and the elimination of the uninsurance tax during the new administration has affected insurance take-up and other outcomes.

In a new study, Benjamin Ukert, PhD, assistant professor in the Department of Health Policy and Management at the Texas A&M University School of Public Health, joined colleagues from the University of Kentucky, Georgia State University and IMPAQ to explore how the administrations’ changes may have affected the health insurance market and the health of people. Their study published in the journal Health Services Research used information from a well-regarded national telephone survey of American adults (the Behavioral Risk Factor Surveillance System [BRFSS]) from 2011 to 2018 to analyze these effects. Ukert and colleagues focused on measures of self-reported health and access to medical care to determine whether the improvements seen from 2014 to 2016 continued in 2017 and 2018.

The research team collected data on the likelihood of having health insurance coverage, the occurrence of cost being a barrier to seeking medical care, whether subjects had a primary care doctor and whether people had a checkup within the past year. They also reported on data on overall self-reported health, the number of days in the previous month where people were not in good physical or mental health or were limited by health issues. By using data from 2011 to 2018, Ukert and colleagues could compare outcomes before and after the ACA was signed into law and into the first two years of the new administration.

Ukert and colleagues analyzed these data using a new statistical approach that can separate the effects of state Medicaid expansions and other national parts of the ACA like the individual insurance marketplace. They found that insurance coverage increased between 2014 and 2016, as shown in previous research, and that the increasing trend continued in 2017 and 2018. States that expanded their Medicaid programs saw larger increases in insured people; however, other aspects of the ACA, such as insurance mandates and subsidized marketplace plans, accounted for more than half of those increases.

The research team also investigated self-reported health outcomes after the five years of the ACA because improvements in health care take time, and improvements in health may take time and only materialize after a person received health coverage and received health enhancing medical care. Their analysis found no significant changes in self-reported health for 2014, but small and growing changes afterward that did not seem to be affected by changes to the ACA starting in 2017.

Although their analysis shows that administrative changes to the ACA and public debate over the law appear to have had no effect on coverage or health outcomes, they state that potential long-term consequences of these changes may appear in the future. Recently, more states have joined those that have expanded their Medicaid programs and more may do so in the future. These expansions call for further studies into how the ACA affects health care access and health. However, the findings of this study serve to confirm previous research findings and shed greater light on how the ACA and continuous changes to the law affect access to health care and self-reported health of Americans.



Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A. and Zapata, D., 2018. Effects of the Affordable Care Act on health care access and self-assessed health after 3 years. INQUIRY: The Journal of Health Care Organization, Provision, and Financing55, p.0046958018796361.

— Rae Lynn Mitchell

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